“I find that by a preponderance of the evidence that if the applicants meet and comply with the conditions…the benefits likely to result from the proposed cooperative agreement outweigh the disadvantages likely to result from a reduction in competition from the proposed cooperative agreement,” Dr. Levine said in the letter.

Dr. Levine also committed to establishing measures to evaluate the benefits of the agreement by January 31, 2018.

The conditions of the approval include leaving all Virginia hospitals open as clinical and healthcare institutions for at least five years.

The 49 conditions laid out in the approval take more than 20 pages to list.

Among them:

The two systems may not close, repurpose, merge facilities or terminate employees (except for cause) from now until the effective date of the merger.

Ballad may not contractually require that it be the exclusive provider to any health plan.

Ballad must coordinate in good faith with independent physicians groups to develop a single, region-wide clinical services network, including the sharing of data.

Ballad must fully honor existing employee benefits including full accrual of sick time and vacation.

During the first 24 months, no Virginia employee may be terminated, except for cause, or moved more than 30 miles from his or her current location of employment. After 24 months, if Ballad wishes to terminate more than 50 employees during a 90-day period, it must give the state at least 60 days advance notice.

Ballad must spend at least $85 million on health research and graduate medical education, $85 million on behavioral health services, $75 million on population health improvement, $28 million on rural health services, and $27 million on children’s health services in the 10-year period starting in 2018.

Three members of the 11-member Ballad board must be Virginia residents.